Pelvic organ prolapse (POP)

Anterior compartment prolapse

• Urethrocele - prolapse of the urethra into the vagina
• Cystocele - prolapse of the bladder into the vagina
• Cystourethrocele - prolapse of both urethra and bladder

Middle compartment prolapse

• Uterine prolapse - descent of the uterus into the vagina
• Vaginal vault prolapse - descent of the vaginal vault post-hysterectomy
• Enterocele - herniation of the Pouch of Douglas (including small intestine/omentum) into the vagina

Posterior compartment prolapse

• Rectocele - prolapse of the rectum into the vagina

POP quantification system:

• Stage 0 - no prolapse
• Stage I - most distal portion of the prolapse is >1cm proximal to the level of the hymen
• Stage II - most distal portion of the prolapse is <1cm proximal or distal to the level of the hymen
• Stage III - most distal portion of the prolapse is <1cm beyond the hymen but protrudes no further than 2cm less than total length of vagina
• Stage IV - complete vaginal eversion

Degree of uterine descent:

• 1^st degree - cervix visible when the perineum is depressed – prolapse contained within the vagina
• 2^nd degree - cervix prolapsed through the introitus with the fundus remaining in the pelvis
• 3^rd degree -  procidentia (complete prolapse) – entire uterus is outside the introitus

History:

• Specific symptoms related to POP
• Symptoms effect on the patient’s quality of life
• Any modifiable risk factors for POP?
  • excess weight
  • chronic cough
  • constipation

Initial examination should include:

• Pelvic examination
  • observe the woman at rest and while straining
  • examine the woman both standing and supine
  • examination should be done with an empty bladder
• Rectal examination may be useful if there are bowel symptoms

Treatment is unnecessary in women who are asymptomatic.

Conservative management should be considered 1^st line.

• Lifestyle advice / treatment to reduce modifiable risk factors should be given
  • weight loss
  • treatment of constipation
  • smoking cessation – may improve chronic cough

• Patients with stage I-II prolapse should be offered referral to the women’s health physiotherapist for pelvic floor muscle training: Megan Alexander - Dumfries; Vari Vance - Stranraer
  • patients who have previously had surgery for POP are still suitable for physiotherapy referral
  • patients will be referred by the physiotherapist directly to gynaecology if she thinks they would be more appropriate to manage the patient

• Vaginal estrogen will not cure prolapse but should be considered if postmenopausal since:
  • discomfort may be related to vaginal atrophy rather than prolapse
  • if surgery required, improved healing with estrogenised epithelium
  • used with supporting ring pessary facilitates pessary change and reduces granulation tissue

• Patients with stage III-IV prolapse should be offered trial of vaginal pessary
  • this can be done in the GP surgery if someone has the skills
  • patients can be referred to gynaecology for initial pessary referral if no one feels confident doing this in the surgery
  • once a pessary has been fitted and there have been no issues between changes the patient will likely be discharged to GP for further changes

Surgical management is offered to patients who:

• have a large symptom burden
• have declined conservative management
• failed to respond to conservative management

Patient choice should be taken into account when making the referral.